Prehospital Academy Lesson 10.4
This lesson elaborates on the critical skill of history taking within the context of EMS patient assessment. Following primary assessment and the initial transport decision, a thorough history provides invaluable subjective information that guides the secondary assessment, helps formulate a field diagnosis, and informs the overall treatment plan.
The Role of History Taking in Patient Assessment
While the primary assessment focuses on immediate life threats, history taking gathers subjective data information provided by the patient, family, or bystanders. This contrasts with objective data (e.g., vital signs, physical exam findings) that can be directly measured or observed. In many medical emergencies, the history is the most important component for understanding the patient's condition.
Effective history taking is an art that requires active listening, empathy, and the ability to ask clear, open-ended questions. It helps build rapport with the patient, which can be crucial for obtaining accurate and comprehensive information.
SAMPLE History: A Foundation for Medical Patients
The SAMPLE acronym is a widely used and effective method for gathering a comprehensive patient history, particularly in medical emergencies:
S - Signs and Symptoms: What can you observe (signs) and what does the patient tell you they feel (symptoms)? This includes the chief complaint.
A - Allergies: Does the patient have any allergies to medications, food, or environmental factors? This is critical for preventing adverse reactions.
M - Medications: What medications is the patient currently taking (prescription, over-the-counter, herbal remedies)? Include dosage and last dose taken.
P - Pertinent Past Medical History: Does the patient have any underlying medical conditions, previous surgeries, or hospitalizations that might relate to their current complaint?
L - Last Oral Intake: When did the patient last eat or drink, and what was it? This is important for potential airway management and surgical considerations.
E - Events Leading to Present Illness/Injury: What was the patient doing when the symptoms started? What were the circumstances surrounding the incident?
OPQRST: Characterizing Pain or Discomfort
When the patient's chief complaint involves pain or discomfort, the OPQRST mnemonic helps gather detailed information about that specific symptom:
O - Onset: When did the symptom begin? Was it sudden or gradual?
P - Provocation/Palliation: What makes the symptom worse (provocation) or better (palliation)?
Q - Quality: How would the patient describe the pain (e.g., sharp, dull, crushing, burning)?
R - Radiation: Does the pain move or spread to other parts of the body?
S - Severity: How severe is the pain on a scale of 0-10, or using a descriptive scale (e.g., mild, moderate, severe)?
T - Time: Has the pain been constant, intermittent, or has it changed over time?
History Taking in Trauma Patients
While SAMPLE and OPQRST are primarily for medical patients, elements of history taking are still vital in trauma. The focus shifts to the mechanism of injury and associated complaints. Key questions include:
What happened? (e.g., fall, motor vehicle collision, assault)
What was the height of the fall?
What speed was the vehicle traveling?
Where do you hurt?
Were you wearing a seatbelt/helmet?
In trauma, objective findings from the physical exam often take precedence, but the history helps guide the targeted physical assessment.
Pitfalls and Best Practices
Common pitfalls in history taking include:
Leading questions that suggest an answer.
Interrupting the patient.
Failing to listen actively.
Focusing solely on the chief complaint and missing other pertinent information.
Best practices for EMTs:
Allow the patient to tell their story in their own words initially.
Use open-ended questions (e.g., "Can you tell me more about that?" instead of "Does it hurt here?").
Confirm understanding of the patient's complaints.
Always ask about allergies and medications.
Be aware of cultural sensitivities and communicate respectfully.
Critical Thinking Questions
You are dispatched to a patient complaining of chest pain. After addressing immediate life threats, how would you use the OPQRST mnemonic to gather detailed information about their pain, and why is each component important?
An elderly patient living alone presents with altered mental status. Their neighbor called 911 but has limited information. What elements of the SAMPLE history would you prioritize, and what are the challenges in obtaining this information in such a scenario?
A patient who is a non-English speaker is experiencing severe abdominal pain. How can you ensure effective communication and accurate history taking, both with and without the presence of an interpreter?
You respond to a patient who fell from a ladder. They deny any pain other than a minor abrasion on their arm. Given the mechanism of injury, what further history questions would you ask to maintain a high index of suspicion for other potential injuries?
Discuss how the information gathered during a thorough history can directly influence your treatment plan and transport decision for both a medical patient with respiratory distress and a trauma patient with a possible head injury.